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The Patient's Story

Mr N is a 77-year-old retired systems theorist and educator with pancreatic cancer metastatic to his liver and lungs. Two years after diagnosis, he has outlived his physicians' (and his own) expectations about prognosis. Treatment with capecitabine has successfully controlled his disease. He has had several episodes of sepsis from biliary obstruction and has an external biliary stent. Chronic medical problems—back pain, gastrointestinal tract bleeding, dyspepsia, malabsorption, diarrhea, and urinary retention—are controlled with celecoxib, ursodeoxycholic acid, ferrous gluconate, morphine, omeprazole, vitamin K, pancreatic enzymes, loperamide, and terazosin.

Mr N is divorced, with a son who lives 2000 miles away. He and his son enjoy a close relationship, although the frequency of their visits is limited by distance. Mr N maintains a cordial relationship with his ex-wife, enjoys many friendships, and has strong connections with his family and physicians. His economic circumstances are secure.

Perspectives

DR S:I met him [18 years ago] for a new patient evaluation for low back pain. He is a retired college professor who had divorced from his wife about 3 years before…He had been on the faculty at a university as an organizational psychologist and taught there for many years. He had decided to retire early and move to California, where he was doing a lot of freelance activities and consulting as an organizational psychologist.

He was always very articulate, extremely intelligent, and very warm and caring. He's a lovely man. He was very organized. He'd always come with things written down. Since his illness, he's taken to taping all of our encounters, that's…been helpful because he tends to ask a lot of questions. When I first met him they were all medically related questions about side effects, expected time courses, and things like that. Now they're much more wide-ranging questions about life and death…He asked me 2 visits ago about how he would likely die. We've talked previously about the settings where he might die.

MR N:At 77 any time I have left is frosting…This term "life-threatening illness" isn't any more life threatening than if I didn't have an illness…It's part of what goes with living. I'm perfectly content with the thought that it's the end.

MR N'S SON:The end of life. There's nothing good about his eventually dying. There's no upside to that. There's certainly a lot of good to my having this time with him. That's a great thing.

Mr N is an articulate, reflective, and warm man. Several painful losses have served as a stimulus for self-reflection and growth. He has developed an eclectic but firm sense of values and beliefs. Mr N's unusual equanimity in the face of his death offers a "best possible" scenario for the end of life. However, despite all ...